The effect of heparins on plasma concentration of heparin-binding protein: a pilot study

Background: Neutrophil-derived heparin-binding protein (HBP) plays a role in the pathophysiology of impaired endothelial dysfunction during inflammation. HBP has been suggested as a predictor of organ dysfunction and disease progression in sepsis. We investigated the effects of heparins on plasma concentrations of HBP in patients undergoing surgery. Methods: We studied three groups of patients receiving heparins during or after surgery. The vascular surgery group received 3000–7500 U, whereas the cardiac surgery group received 27 500–40 000 U. After major general surgery, the third group received 5000 U of low-molecular-weight heparin (LMWH) subcutaneously. Serial plasma HBP concentrations were measured after these treatments with two different methods: Axis-Shield ELISA and Joinstar FIC-Q100. In addition, plasma myeloperoxidase and syndecan-1 were measured in the cardiac surgery group. Results: During vascular surgery, heparin induced a six-fold increase in HBP within 2 min, from 3.6 (2.4–5.4) to 21.4 (9.0–35.4) ng ml−1 (P<0.001). During cardiac surgery, the higher dose of heparin elevated HBP concentrations from 5.3 (2.7–6.1) to 48.7 (38.4–70.1) ng ml−1 (P<0.0001) within 3 min. Patients receiving LMWH showed an increase from a baseline of 5.7 (3.7–12.1) ng ml−1 to a peak HBP concentration of 14.8 (9.5–18.1) ng ml−1 (P<0.0001) after 3 h. Plasma concentrations of myeloperoxidase, but not syndecan-1, also responded with a rapid increase after heparin. There was a strong correlation between the two methods for HBP analysis (r=0.94). Conclusions: Plasma concentrations of HBP increased rapidly and dose-dependently after heparin administration. Subcutaneous administration of LMWH increases plasma HBP, but to a lesser degree. Clinical trial registration: ClinicalTrials.gov identifier: NCT04146493

Endocarditis caused by Lactococcus cremoris

To access publisher full text version of this article. Please click on the hyperlink in Additional Links fieldWe describe a case of subacute endocarditis due to Lactococcus cremoris associated with consumption of unpasteurized milk. Treatment with amoxicillin-clavulanic acid and subsequently penicillin resulted in prompt sterilization of this patient's bloodstream and full recovery

Neuro-intensive treatment targeting intracranial hypertension improves outcome in severe bacterial meningitis: an intervention-control study.

OBJECTIVE: To evaluate the efficacy of early intracranial pressure (ICP)-targeted treatment, compared to standard intensive care, in adults with community acquired acute bacterial meningitis (ABM) and severely impaired consciousness. DESIGN: A prospectively designed intervention-control comparison study of adult cases from September 2004 to January 2012. PATIENTS: Included patients were confirmed ABM-cases, aged 16-75 years, with severely impaired mental status on admission. Fifty-two patients, given ICP-targeted treatment at the neuro-intensive care unit, and 53 control cases, treated with conventional intensive care, were included. All the patients received intensive care with mechanical ventilation, sedation, antibiotics and corticosteroids according to current guidelines. Additional ICP-treatment in the intervention group included cerebrospinal fluid drainage using external ventricular catheters (n = 48), osmotherapy (n = 21), hyperventilation (n = 13), external cooling (n = 9), gram-doses of methylprednisolone (n = 3) and deep barbiturate sedation (n = 2) aiming at ICP <20 mmHg and a cerebral perfusion pressure of >50 mmHg. MEASUREMENTS: The primary endpoint was mortality at two months and secondary endpoint was Glasgow outcome score and hearing ability at follow-up at 2-6 months. OUTCOMES: The mortality was significantly lower in the intervention group compared to controls, 5/52 (10%) versus 16/53 (30%; relative risk reduction 68%; p<0.05). Furthermore, only 17 patients (32%) in the control group fully recovered compared to 28 (54%) in the intervention group (relative risk reduction 40%; p<0.05). CONCLUSIONS: Early neuro-intensive care using ICP-targeted therapy, mainly cerebrospinal fluid drainage, reduces mortality and improves the overall outcome in adult patients with ABM and severely impaired mental status on admission

The intracranial pressure (ICP; mmHg) as noted at operation (external ventricular drainage: n = 48; parenchymal ICP-monitor: n = 4), and the highest levels of ICP, noted continuously during episodes >5 min, at the neuro-intensive care unit (NICU), related to the outcome at follow-up after 2–6 months in the intervention per protocol group.

<p>GOS = Glasgow outcome score.</p><p>*These patients ended up as follows;</p><p>a) Two with GOS 3, two with GOS 4.</p><p>b) Four with GOS 4.</p><p>c) One with GOS 3, four with GOS 4.</p><p>d) Two with GOS 4.</p

Outcomes at follow-up after 2–6 months in the intervention group and in the controls.

<p>NICU = neuro-intensive care unit. GOS = Glasgow outcome score.</p><p>*p<0.05 with two-tailed Fisher's exact test when comparing the intention to treat group, and the per protocol group, with the control group.</p>a<p>Patients included as final controls according to inclusion and exclusion criteria.</p

Intracranial pressure (ICP)-targeting therapy used in the intervention group, (n = 52, external ventricular drainage; n = 48, parenchymal ICP-monitor; n = 4).

<p>Csf = cerebrospinal fluid; NICU = neuro-intensive care unit.</p

The algorithm for treatment of increased intracranial pressure (ICP) in the neuro-intensive care unit (n = 52).

<p>An external ventricular drainage (EVD) was established at operation in 50 patients with initial cerebrospinal fluid (Csf) drainage in 48 of these. A parenchymal ICP-monitor (Codman) was inserted in four cases. Bolus doses of Mannitol were administered in five cases prior to neuro-intervention. The shaded numbers represent different patients.</p

The highest levels of intracranial pressure (ICP), as observed continuously during episodes of more than 5 min, in the neuro-intensive care unit after initial cerebrospinal fluid drainage at operation; n = 52 (external ventricular drainage; n = 48, parenchymal ICP-monitor; n = 4).

<p>The highest levels of intracranial pressure (ICP), as observed continuously during episodes of more than 5 min, in the neuro-intensive care unit after initial cerebrospinal fluid drainage at operation; n = 52 (external ventricular drainage; n = 48, parenchymal ICP-monitor; n = 4).</p

The algorithm for inclusion and exclusion of patients.

<p>Inclusion criteria were: 1) age 16–75 years, 2) severely impaired mental status on admission, and 3) confirmed acute bacterial meningitis (ABM). Patients were initially included in the intervention group based on clinical suspicion of ABM with or without cerebrospinal fluid analysis. SQRM = Swedish National Quality Registry for ABM. ICP = intracranial pressure. NICU = neuro-intensive care unit. ICU = intensive care unit.</p

The main characteristics regarding demographic, etiological, clinical, and laboratory data, not identifying any significant difference between the intervention and control group, including comparison of the reaction level scale (RLS) values that were converted from Glasgow coma score (GCS) in the intervention group [27], [43].

<p>LP = lumbar puncture. Csf = cerebrospinal fluid.</p><p>When data was missing the numbers of patients with available data are shown [in brackets].</p>a<p>Malignancy/immunosuppresion: n = 10, Alcoholism: n = 5, Diabetes: n = 3, Splenectomized: n = 1, CSF-leakage: n = 1,</p>b<p>Malignancy/immunosuppresion: n = 5, Alcoholism: n = 3, Diabetes: n = 3, Splenectomized: n = 2, CSF leakage: n = 2.</p>c<p><i>S aureus</i>: n = 2, <i>L monocytogenes</i>: n = 1.</p>d<p><i>S aureus</i>: n = 4, <i>H influenzae</i>: n = 2, <i>L monocytogenes</i>: n = 1, <i>S pyogenes</i> geoup C: n = 1, <i>E cloacae</i>: n = 1.</p>e<p>Two tailed Fisher's exact test for proportions and Student T-test for normally distributed values.</p